Index

About the Medical Plan

Eligibility and Enrollment

Basic Plan Features

The Prescription Drug Program

Mental Health and Chemical Dependency Care

Covered Expenses

Exclusions

Payments

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary 		 

blue square Benefit Summary

Please note: This chart provides only a brief summary of benefits under this option. It is not intended to include all POS II Option provisions. Non-network and out-of-network area benefits are subject to reasonable and customary limits.

Services POS II Network Non-Network Out-of-Network Area
Annual Deductible Individual/Family

 $300/$600 $300/$600 $300/$600
Out-of-Pocket Maximum
Individual/Family

 $3,000/$6,000 $12,000/$24,000 $3,000/$6,000
Individual Lifetime Maximum

 $6,000,000 $6,000,000 $6,000,000
Separate Lifetime Maximum for Bariatric Surgery (included in $6M lifetime maximum) $25,000 $25,000 $25,000
Pre-certification Required for inpatient hospitalization, treatment facility, skilled nursing care, home health care, hospice care & durable medical equipment Provider initiates You initiate; $500 penalty for failure to pre-certify inpatient care You initiate; $500 penalty for failure to pre-certify inpatient care
Inpatient Hospital Services1 $75 deductible
80% coverage		 $150 deductible
60% coverage		 $75 deductible
80% coverage
Outpatient Surgery and Associated Diagnostic Lab and 
X-ray Services		 80% coverage 60% coverage 80% coverage
Services POS II Network Non-Network Out-of-Network Area
Physician Services*      
Surgeon/Hospital Doctor Visits 80% coverage 60% coverage 80% coverage
Office Visit (including most diagnostic lab and X-ray services)2 $20 co-pay3 primary care
$30 co-pay3 specialist		 60% coverage 80% coverage
Preventive Care (including most diagnostic lab and X-ray services)2

*PCP selection is not required

 $20 co-pay3 primary care
$30 co-pay3 specialist		 60% coverage 80% coverage
Prescription Drugs

Annual out-of-pocket maximums for prescription drugs
$2,000/individual and $4,000/family
 

Retail Co-Pay* ** ***

Medco by Mail
 

(up to 34-day supply)

 3rd+ Retail Refill**** (up to 90-day supply)
  ($100 max per Rx) ($150 max per Rx)
Generic Drugs 30% 55% 25%
Formulary
Brand Drugs		 30% 55% 25%
Non-Formulary
Brand Drugs		 50% 75% 45%

* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail co-pays.

** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic co-pay and the difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand name and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.

*** You must present your Prescription Drug Identification Card (Medco Card) or the primary participant's identification number, or benefits will be paid at the non-network level.

**** Additional 25% coinsurance does not apply to the annual out-of-pocket maximum for prescription drugs.
Services POS II Network Non-Network Out-of-Network Area
Emergency Care

 $75 deductible4
80% coverage		 $75 deductible4
80% coverage		 $75 deductible4
80% coverage

Maternity

 80% coverage 60% coverage 80% coverage
Chiropractic Care5 $30 co-pay;3 $1,000 calendar year limit 60% coverage; $1,000 calendar year limit 80% coverage; $1,000 calendar year limit
Services POS II Network Non-Network Out-of-Network Area
Mental Health
Note: No benefit will be paid unless pre-certified through Magellan Behavioral Health, except for non-network inpatient care.1 		    Overseas only
Inpatient $75 deductible
80% coverage		 $150 deductible
50% coverage up to 30 days per calendar year		 $75 deductible
80% coverage
Outpatient Office Visits $30 co-payment3 50% coverage up to 52 visits per calendar year. No out-of-pocket maximum 80% coverage

Chemical Dependency1
Note: No benefit will be paid unless pre-certified through Magellan Behavioral Health.

    Overseas only
Inpatient $75 deductible
80% coverage - 4 (four) admissions per lifetime		 $150 deductible
50% coverage up to 30 days per calendar year and 4 admissions per lifetime		 $75 deductible
80% coverage - 4 (four) admissions per lifetime.
Outpatient $30 co-payment3 50% coverage up to 52 visits per calendar year. No out-of-pocket maximum 80% coverage

1 Pre-certification is required for all mental health care, except non-network inpatient care, in order to be eligible for any reimbursement. However, if non-network inpatient care is not pre-certified, it may be reimbursed at 40% of the network rate.
2 Excluding MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography.
3 Not subject to deductible.
4 This charge will be applied to the hospital deductible if admitted.
5 Calendar year limit applies to all chiropractic expenses regardless of network status of provider.